In orthopaedic surgery it is often necessary to insert a guide pin for a cannulated screw, drill bit, or other screw (hereafter referred to as a fixation device) into a bone at a predetermined trajectory. Pre-operative planning depends on two-dimensional radiographic images which typically consist of two views taken at approximately right angles to one another. From these two views it is possible to determine the shape and structure of a long bone. Using that method, the path of insertion for a guide pin for a cannulated screw, drill bit, or screw is accurately determined. However, in practice the actual aiming of a fixation device is an inaccurate art, as the object bone is often seen only at one surface or is not seen at all and, therefore, positioning is dependent on fluoroscopic visualization. This method is also time consuming as the C-arm images must be taken separately and the drapes must be rearranged each time an image is taken. As boney tissue is unyielding, the track of the pin or drill bit is determined by the angular approach before entering the object bone. This angular approach is difficult to determine under normal circumstances and often multiple attempts are needed, as feedback is obtained from repeated fluoroscopic images. Existing methods of calculating the proper angle of guide pin for a cannulated hip screw insertion for hip pinning involve placing data manually into a computer program, which in turn outputs an angle of guide pin for a cannulated hip screw insertion.
Radiation exposure is a necessary part of any procedure for calculating the proper angle of a guide pin, drill bit, or screw insertion. Radiation exposure is considered to be a hazard. Ionizing radiation has no safe threshold of exposure below which it ceases to have adverse effects, although an arbitrary level is assumed. There has been a recent upward revision of risk estimates of radiation exposure, but absolute levels of safe exposure remain unknown. Exposure to the surgical team as well as the patient during orthopaedic procedures using fluoroscopy is a universal concern. Consequently, a reduction in the amount of radiation exposure is highly desirable.
Operative stereotactic localization using either frames or three-dimensional digitizers is currently being used in neurosurgery or otoloaryngology. Those methods require the use of computed axial tomography (CT) or magnetic resonance imaging (MRI) prior to surgery. They also involve placing markers on the scalp prior to the imaging study of the head. The markers must be left in the same position until surgery is performed in order to confirm intraoperative registration. Such imaging studies are routinely performed for most intracranial procedures but are impractical for most orthopaedic procedures, especially those involving long bones. A probe marked with light emitting diodes (LEDs) or other digitizing emitters is used to localize these markers or pins using a three-dimensional digitizing device at the time of surgery. A disadvantage of this system is that the images are normally obtained hours before use; thus, the images used are not up to date (real time) and are often not reflective of the current condition of the object bone.
Registration markers cannot be used on the outside of the body in most orthopaedic cases as the skin does not adhere to the underlying bone. Pre-operative registration for robotic placement of the femoral components for total hip arthroplasty requires the use of a separate procedure to insert screws for such markers. Such a separate procedure is highly impractical for routine orthopaedic procedures.
An alternative method of registration for image guided surgery requires wide operative exposure, such as in pedicle screw insertion in spine surgery. The various fiducials are determined by touching prominent or distinctive anatomic points with a digitizing probe as employed by the stereotactic localization system. Furthermore, the system also requires preoperative computed axial tomography.
A system using fluoroscopic images to guide the insertion of a fixation device employs tracking with a three-dimensional optical digitizer. This optical digitizer is used to determine the position in six degrees of freedom of a portable fluoroscopy machine (“C-arm fluoroscope”) and the object region of the skeleton. Light emitting diodes (“LEDs”) are placed in distinctive patterns on the C-arm. Another set of LEDs are attached to the bone with a percutaneous screw device, such as a reference bar. A computer program records these positions in relation to an optical position sensor.
X-rays are then taken with the C-arm fluoroscope with the two positions of the tube at approximate right angles to one another. The optical position sensor can thus determine where the C-arm is positioned in relation to LED markers attached to the reference bar attached to the object section of the skeleton. The exact position is determined by using two-dimensional image registration, matching the outline of the bone in two planes. In this system, three or more distinctly shaped radiographic markers are attached to threaded tipped registration pins inserted percutaneously. Thus, the object portion of the skeleton is localized in six degrees of freedom by the optical digitizer.
The computer program relates the position of the object bone with or without fiducial markers in the two fields to determine the exact relative position of the object bone seen on the two images. Once those two images are displayed on monitors, no further x-rays are needed. Thus, a substantial reduction in the amount of ionizing radiation results. The images displayed are those familiar to the surgeon but with the usual distortion eliminated.
A drill with attached LEDs inserts the fixation device in the position in the bone that the surgeon chooses based on the supplied information. The three-dimensional optical digitizer determines the position of the drill in relation to the optical digitizer camera and the object section of the skeleton with its fiducials. A graphic display of the fixation device of predetermined length is then overlaid on the images of the object bone in near real time. Thus, the position of the inserted pin or drill bit can be adjusted immediately.